Chapter 41: Fluid, Electrolyte and Acid-Base Balance

A client is admitted to the unit with a diagnosis of intractable vomiting for 3 days. What acid-base imbalance related to the loss of stomach acid does the nurse observe on the arterial blood gas (ABG)? Respiratory acidosis Metabolic acidosis Metabolic alkalosis Respiratory alkalosis

Metabolic alkalosis

An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as: total parenteral nutrition. cellular hydration. volume expander. blood transfusion therapy.

total parental nutrition

The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response? "Watery plasma, or serum, portion of blood." "Fluid inside cells." "Fluid in the tissue space between and around cells." "Fluid outside cells."

"Fluid in the tissue space between and around cells."

The nurse is caring for a client who will be undergoing surgery in several weeks. The client states, "I would like to give my own blood to be used in case I need it during surgery." What is the appropriate nursing response? "Unfortunately, your own blood cannot be reinfused during surgery." "Let me refer you to the blood bank so they can provide you with information." "We now have artificial blood products, so giving your own blood is not necessary." "This surgery has a very low chance of hemorrhage, so you will not need blood."

"Let me refer you to the blood bank so they can provide you with information."

What commonly used intravenous solution is hypotonic? 0.9% NaCl lactated Ringer's 10% dextrose in water 0.45% NaCl

0.45% NaCl

A client has been diagnosed with a gastrointestinal bleed and the health care provider has ordered a transfusion. At what rate should the nurse administer the client's packed red blood cells? 1 unit over 2 to 3 hours, no longer than 4 hours 200 mL/hr As fast as the client can tolerate 75 mL/hr for the first 15 minutes, then 200 mL/hr

1 unit over 2 to 3 hours, no longer than 4 hours

A health care provider orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/ml What is the flow rate? 20 gtt/min 50 gtt/min 40 gtt/min 30 gtt/min

50 gtt/ min

A health care provider orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/ml What is the flow rate? 50 gtt/min 30 gtt/min 40 gtt/min 20 gtt/min

50 gtt/min

A health care provider has asked the nurse to use microdrip tubing to administer a prescribed dosage of IV solution to a client. What is the standard drop factor of microdrip tubing? 90 drops/mL 60 drops/mL 30 drops/mL 120 drops/mL

60 drops/mL

What is the lab test commonly used in the assessment and treatment of acid-base balance? Urinalysis Basic metabolic panel Complete blood count Arterial blood gas

Arterial blood gas

The nurse is educating a client with hypokalemia on why it is important to maintain potassium balance. Which does the nurse include in the teaching? Neurologic function Cardiac function Visual acuity Skeletal integrity

Cardiac Function

Which is a common anion? calcium magnesium chloride potassium

Chloride

The nurse is administering 1,000 mL 0.9 normal saline over 10 hours (set delivers 60 gtt/1 mL). Using the formula below, the flow rate would be: gtt/min = milliliters per hour x drop factor (gtt/mL) ÷ 60 min/hr 60 gtt/ min 600 gtt/min 100 gtt/min 6000 gtt/ min

Correct response: 100 gtt/min

A nurse is caring for a client who requires intravenous (IV) therapy. The nurse understands that which actions are the nurse's responsibilities related to this therapy? Select all that apply. Deciding the location of the IV catheter. Determining the amount of IV solution. Prescribing the kind of IV solution. Administering the IV solution. Deciding the size of the IV catheter.

Deciding the location of the IV catheter. Deciding the size of the IV catheter. Administering the IV solution.

A nurse inspecting a client's IV site notices redness and swelling at the site. What would be the most appropriate nursing intervention for this situation? Stop the infusion, cleanse the site with alcohol, and apply transparent polyurethane dressing over the entry site. Call the primary care provider to see whether anti-inflammatory drugs should be administered. Cleanse the site with chlorhexidine solution using a circular motion and continue to monitor the site every 15 minutes for 6 hours before removing the IV Discontinue the IV and relocate it to another site.

Discontinue the IV and relocate it to another site.

A client is receiving a peripheral IV infusion and the electronic pump is alarming frequently due to occluded flow. What is the nurse's most appropriate action? Flush the IV with 3 mL of normal saline. Assess the area distal to the IV site for signs and symptoms of deep vein thrombosis. Change from infusion with an electronic pump to infusion by gravity. Flush the IV with 2 mL of 100 U/mL heparin.

Flush the IV with 3 mL of normal saline.

A nurse is changing a client's peripheral venous access dressing. The nurse finds that the site is bleeding and oozing. Which type of dressing should the nurse use for this client? Transparent semipermeable membrane dressing Sealed IV dressing Occlusive dressing Gauze dressing

Gauze dressing

A nurse is obtaining an arterial blood specimen from a client to assess acid-base status. Which value is expected for a client with normal status? HCO3: 25 mEq/L (25 mmol/L) PaCO2: 48 mm Hg (6.38 kPa) pH: 6.45 SaO2: 89%

HCO3: 25 mEq/L (25 mmol/L)

During an assessment of an older adult client, the nurse notes an increase in pulse and respiration rates, and notes that the client has warm skin. The nurse also notes a decrease in the client's blood pressure. Which medical diagnosis may be responsible? circulatory overload hypovolemia hypervolemia edema

Hypovalemia

A nurse is assessing clients across the lifespan for fluid and electrolyte balance. Which age group would the nurse identify as having the greatest risk for these imbalances? Infants Toddlers Adolescents School-age children

Infants

As observed the nurse changing a peripheral venous access site dressing is demonstrating inappropriate technique by implementing which action? Not performing the intervention under sterile conditions Not wearing gloves when performing the intervention By applying stabilizing pressure to the catheter By pulling the dressing toward the insertion site

Not wearing gloves when performing the intervention

The nurse is caring for a client whose blood type is A negative. Which donor blood type does the nurse confirm as compatible for this client? A positive O negative B positive AB negative

O negative

The nurse has just successfully inserted an intravenous (IV) catheter and initiated IV fluids. Which items should the nurse document? Select all that apply. Gauge and length of the IV catheter Manufacturer of the IV catheter Type of IV solution Location of the IV catheter access Rate of the IV solution Client's reaction to the procedure

Rate of the IV solution Location of the IV catheter access Client's reaction to the procedure Type of IV solution Gauge and length of the IV catheter

A client's blood pressure has dropped from 146/92 mmHg to 107/68 mmHg over the course of several minutes. Increased levels of which of the following will be released into the client's bloodstream? Insulin Erythropoietin Renin Protein

Renin

The primary extracellular electrolytes include which of the following? Potassium, phosphate, and sulfate Sodium, chloride, and bicarbonate Phosphorous, calcium, and phosphate Magnesium, sulfate, and carbon

Sodium, chloride, and bicarbonate

A nurse is presenting an in-service program to a group of graduate nurses about blood component therapy. The nurse determines that the education was successful when the group identifies which complication as the primary cause of transfusion-related client death in the United States? Septic reaction Transfusion-associated circulatory overload Hemolytic reaction Transfusion-related acute lung injury

Transfusion-associated circulatory overload

The oncoming nurse is assigned to the following clients. Which client should the nurse assess first? a 60-year-old who is 3 days post-myocardial infarction and has been stable. a 20-year-old, 2 days postoperative open appendectomy who refuses to ambulate today a newly admitted 88-year-old with a 2-day history of vomiting and loose stools a 47-year-old who had a colon resection yesterday and is reporting pain

a newly admitted 88-year-old with a 2-day history of vomiting and loose stools

The nurse writes a a problem-based care plan, citing the client's excess fluid volume. What risk factor does the nurse expect to assess in this client? acute kidney injury increased cardiac output diaphoresis excessive use of laxatives

acute kidney injury

Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid? an infant age 4 months a man age 50 years a woman age 45 years an adolescent age 17 years

an infant age 4 months

A nurse is reviewing the dietary intake of a client prescribed a potassium-sparing diuretic. The client tells the nurse that they had a banana, yogurt, and bran cereal for breakfast and a turkey sandwich with a glass of milk for lunch. The intake of which food would be a cause for concern? milk banana turkey yogurt

banana

The nurse is caring for a client who had a parathyroidectomy. Upon evaluation of the client's laboratory studies, the nurse would expect to see imbalances in which electrolytes related to the removal of the parathyroid gland? potassium and sodium potassium and chloride calcium and phosphorus chloride and magnesium

calcium and phosphorus

A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L), a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor? cardiac irregularities muscle weakness metabolic acidosis increased intracranial pressure (ICP)

cardiac irregularities

A client who is admitted to the health care facility has been diagnosed with cerebral edema. Which intravenous solution needs to be administered to this client? colloid solution hypertonic solution hypotonic solution isotonic solution

hypertonic solution

nurse is reviewing the client's serum electrolyte levels which are as follows:Sodium: 138 mEq/L (138 mmol/L)Potassium: 3.2 mEq/L (3.2 mmol/L)Calcium: 10.0 mg/dL (2.5 mmol/L)Magnesium: 2.0 mEq/L (1.0 mmol/L)Chloride: 100 mEq/L (100 mmol/L)Phosphate: 4.5 mg/dL (2.6 mEq/L)Based on these levels, the nurse would identify which imbalance? hypermagnesemia hyponatremia hypokalemia hypercalcemia

hypokalemia

A nurse is preparing an education plan for a client with heart failure who is experiencing edema. As part of the plan, the nurse wants to describe the underlying mechanism for why the edema develops. Which mechanism will nurse likely address? blockage of the lymph nodes increased hydrostatic pressure decreased colloid oncotic pressure increased capillary permeability

increased hydrostatic pressure

A group of nursing students is reviewing information about body fluid and locations. The students demonstrate understanding of the material when they identify which of the following as a function of intracellular fluid? maintenance of cell size removal of waste transportation of nutrients maintenance of blood volume

maintenance of cell size

A client is admitted to the nursing unit from the emergency department with a diagnosis of hypokalemia. Laboratory results show a serum potassium of 3.2 mEq/l (3.2 mmol/l). For what set of manifestations should the nurse be alert? muscle weakness, fatigue, and constipation muscle weakness, fatigue, and arrythmias diminished cognitive ability and hypertension nausea, vomiting, and constipation

muscle weakness, fatigue, and arrythmias

A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene? asking the client to pump their fist several times asking if the client is right or left handed palpating the veins on the nondominant hand placing the tourniquet on the upper arm for 2 minutes

placing the tourniquet on the upper arm for 2 minutes

A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration? "I need to drink no more than 1,000 mL/day" "I should drink 2,500 mL/day of fluid." "I should drink more than 3,500 mL/day of fluid." "I should drink 1,500 mL/day of fluid."

"I should drink 2,500 mL/day of fluid."

A health care provider orders a bolus infusion of 250 mL of normal saline to run over 1 hour. The set delivers 20 gtt/mL. What is the flow rate in gtt/min? 5,000 gtt/min 42 gtt/min 83 gtt/min 167 gtt/min

83 gtt/min

A client with a diagnosis of colon cancer has opted for a treatment plan that will include several rounds of chemotherapy. What vascular access device is most likely to meet this client's needs? A peripheral venous catheter inserted to the cephalic vein A midline peripheral catheter An implanted central venous access device (CVAD) A peripheral venous catheter inserted to the antecubital fossa

An implanted central venous access device (CVAD)

A client needs an intravenous fluid that will pull fluids into the vascular space. What type of fluid does the nurse prepare to administer as prescribed? Isotonic Hypertonic Osmolar Hypotonic

Hypertonic

When the nurse reviews the client's laboratory reports revealing sodium, 140 mEq/L (140 mmol/L); potassium, 4.1 mEq/L (4.1 mmol/L); calcium 7.9 mg/dL (1.975 mmol/L), and magnesium 1.9 mg/dL (0.781 mmol/L); the nurse should notify the health care provider of what abnormal value? Low calcium High sodium High magnesium Low potassium

Low calcium

An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations? Have a loved one tell the client to drink more. Offer small amounts of preferred beverage frequently. Leave water on the bedside table. Ask the client every hour to drink more fluid.

Offer small amounts of preferred beverage frequently.

A nurse is caring for a client who is not able to take food orally for 10 days and who will be on IV therapy during that period. The nurse knows that the client will likely receive which type of nutrition?

Peripheral parenteral nutrition

The nurse is administering intravenous (IV) therapy to a client. The nurse notices acute tenderness, redness, warmth, and slight edema of the vein above the insertion site. Which complication related to IV therapy should the nurse most suspect? Air embolism Phlebitis Sepsis Infiltration

Phlebitis

When caring for a client who is on intravenous therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which intervention should the nurse perform for this complication? Restart infusion in another vein and apply a warm compress. Position the client on the left side. Apply antiseptic and a dressing. Elevate the client's head.

Restart infusion in another vein and apply a warm compress.

During a blood transfusion of a client, the nurse observes the appearance of rash and flushing in the client, although the vital signs are stable. Which intervention should the nurse perform for this client first? Stop the transfusion immediately. Infuse saline at a rapid rate. Administer oxygen. Prepare to give an antihistamine.

Stop the transfusion immediately.

What is the priority goal for the activity in which the nurse is engaging, related to the administration of a prescribed IV solution? To assure effective administration of the prescribed IV solution To demonstrate effective nursing care in the administration of the prescribed IV solution To provide for effective time management in the administration of the prescribed IV solution To assure the IV solution is appropriate for this administration

To assure the IV solution is appropriate for this administration

An infant is brought to the emergency room with dehydration due to vomiting. After several failed attempts to start an IV, the nurse observes a scalp vein. When accessing the scalp vein, the nurse should use: an 18-gauge needle. an intermittent infusion device. a central venous access. a winged infusion needle.

a winged infusion needle.

A client has been admitted with fluid volume deficit. Which assessment data would the nurse anticipate? Select all that apply. distended neck veins poor skin turgor crackles in the lungs blood pressure 100/48 mmHg heart rate 128/bpm

blood pressure 100/48 mmHg poor skin turgor heart rate 128/bpm

Edema happens when there is which fluid volume imbalance? water excess extracellular fluid volume excess water deficit extracellular fluid volume deficit

extracellular fluid volume excess

A nurse is preparing an education plan for a client with heart failure who is experiencing edema. As part of the plan, the nurse wants to describe the underlying mechanism for why the edema develops. Which mechanism will nurse likely address? increased capillary permeability increased hydrostatic pressure blockage of the lymph nodes decreased colloid oncotic pressure

increased hydrostatic pressure

A client is diagnosed with metabolic acidosis. The nurse develops a plan of care for this client based on the understanding that the body compensates for this condition by: preventing excretion of acids into the urine. increasing the excretion of HCO3− into the urine. increasing ventilation through the lungs. decreasing the excretion of H+ ion into the urine.

increasing ventilation through the lungs.

he nurse is planning to discontinue a peripherally inserted central catheter (PICC) for a client who is prescribed warfarin therapy. Which intervention will individualize care for this client? Ask client to perform Valsalva maneuver. Apply pressure to insertion site for at least 3 minutes. Instruct client to remain flat for 30 minutes. Apply petroleum-based ointment and sterile occlusive dressing.

Apply pressure to insertion site for at least 3 minutes.

An older adult client who takes diuretics for management of hypertension, informs the nurse that they take laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of what health problem? Hypocalcemia Hypothyroidism Hypoglycemia Hypokalemia

Hypokalemia

Because metabolism continually produces acids, maintenance of pH within these incredibly narrow limits depends on two processes: buffering and compensation. Which statement describes a function of buffering? The renal system excretes acids and bases from the body as needed. The lungs, under the control of chemoreceptor areas in the brainstem respiratory center, are responsible for controlling the amount of carbon dioxide in the blood. The kidneys influence the maintenance of the normal acid-base balance by changing the rate of excretion or retention of H+ and HCO3 ions. It helps to prevent large changes in pH by absorbing or releasing H+ ions.

It helps to prevent large changes in pH by absorbing or releasing H+ ions.

During a blood transfusion, a client displays signs of immediate onset facial flushing, hypotension, tachycardia, and chills. Which transfusion reaction should the nurse suspect? hemolytic transfusion reaction: incompatibility of blood product febrile reaction: fever develops during infusion allergic reaction: allergy to transfused blood bacterial reaction: bacteria present in the blood

hemolytic transfusion reaction: incompatibility of blood product

Upon assessment of a client's peripheral intravenous site, the nurse notices the area is red and warm. The client complains of pain when the nurse gently palpates the area. These signs and symptoms are indicative of: phlebitis. a systemic blood infection. an infiltration. rapid fluid administration.

phlebitis.

A client with protracted nausea and vomiting has been receiving intravenous solution at 125 ml/h for the past several hours. The administration of this solution has resulted in an increase in blood pressure because the water in the solution has passed through the semipermeable membrane of blood cells, causing them to swell. What type of solution has the client been receiving? A hypotonic solution A hypertonic solution An isotonic solution Packed red blood cells

A hypotonic solution

A client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action? Apply a warm compress. Slow the rate of IV fluids. Remove the IV. Elevate the arm.

Remove the IV

A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take? Start an IV of normal saline as prescribed. Give the client a glass of orange juice with added sugar. Encourage fluid intake. Allow nothing by mouth.

Start an IV of normal saline as prescribed.

The nurse is preparing a packed red blood cell transfusion for a client. The nurse checks the client's blood type in the electronic medical record (EMR) and notes that it is blood type B. What does this mean? The client has both anti-A and anti-B antibodies. The client has anti-B antibodies. The client is a universal donor. The client has anti-A antibodies.

The client has anti-A

A client sustained severe trauma in a motor vehicle accident and has had 26 units of packed red blood cells infused since admission 2 days previously. What does the nurse predict will be prescribed to replace the clotting factors lost with the infusion of large amounts of packed red blood cells? granulocytes plasma albumin normal saline solution

plasma

A nurse is providing care to a client who is on fluid restriction. Which action by the nurse would be most appropriate? Have the client use an alcohol-based mouthwash every 2 hours to reduce the thirst sensation. Give the client a fluid containing additional sodium to enhance the feeling of fullness. Apply a petroleum-based gel to the client's lips to prevent cracking. Offer the client sugar-free candy to help combat thirst.

Offer the client sugar-free candy to help combat thirst.

The nurse is caring for a client receiving intravenous fluids through a peripheral intravenous catheter (IV). On rounds, the nurse notes that the client's IV site and arm are swollen and cool to the touch. Based on these assessment findings, what will the nurse do next? Place a warm compress over the swollen site. Decrease the rate of the intravenous fluids. Remove the peripheral intravenous catheter. Elevate the swollen extremity on a pillow.

Remove the peripheral intravenous catheter.

The nurse is caring for a client who has an excess of antidiuretic hormone. What phenomenon will inform the nurse's choice of assessments? The client's urine will be exceptionally dilute The client's renal system retain more water The client likely has a decreased sensation of thirst. The client's blood pressure will decrease

The client's renal system retain more water

Which statement most accurately describes the process of osmosis? Water shifts from high-solute areas to areas of lower solute concentration. Plasma proteins facilitate the reabsorption of fluids into the capillaries. Water moves from an area of lower solute concentration to an area of higher solute concentration. Solutes pass through semipermeable membranes to areas of lower concentration.

Water moves from an area of lower solute concentration to an area of higher solute concentration.

In which fluid compartment is most of the body's fluid is located? extracellular intravascular intracellular interstitial

Intracellular